Customer detail

USHP

23
live contracts
0
cannot fire
20
calc types
3
SQL bodies
1
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment263
MedicareMultipleProcedureAdjustment23
LesserOfAdjustment23
MedicareBilateralSurgeryAdjustment23
MedicareMultipleEndoscopyAdjustment23
MedicareMultipleRadiologyAdjustment23
MidLevelProviderAdjustment23
ChargeLevelSqlAdjustment22
MedicareDrug16
PercentOfFees13
MedicareAnesthesia8
MedicareLab8
MedicareRVU8
MedicareDME8
FlatFee7
SqlExpression6
FlatPercentOfCharges2
MedicareASC1
MultipleSurgeryAdjustment1
PercentOfCharges1

Contracts

Each is one fee logic. Base terms are first-match-wins; adjustments all apply, in order. Expand to see the terms.

FL-Aetna-Medicare-Profee2 base · 18 adj
Aetna Medicare
Professional · FL, ASC, Clinic, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the FL-Aetna-Profee-Clinic fee schedule — when FacilityType in Clinic
  2. 100% of the FL-Aetna-Profee-Hospital fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
FL-Aetna-Profee2 base · 18 adj
Aetna Commercial
Professional · FL, ASC, Clinic, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the FL-Aetna-Profee-Clinic fee schedule — when FacilityType in Clinic
  2. 100% of the FL-Aetna-Profee-Hospital fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
FL-BCBS-Profee1 base · 18 adj
BCBS FL Blue Card, BCBS FL Blue Options, BCBS FL Blue Select, BCBS FL Federal, BCBS FL Health Options, BCBS FL My Blue HMO, BCBS FL PPO, BCBS FL PPO State Employees, BCBS FL Simply Blue
Professional · FL, ASC, Clinic, Hospital · 2025-08-15 → 2999-12-31
Base terms — first match wins
  1. 100% of the FL-BCBS-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
FL-UHC Medicare-Profee6 base · 18 adj
United Healthcare Medicare
Professional · FL · 2025-08-15 → 2999-12-31
Base terms — first match wins
  1. 60% of Medicare lab
  2. 100% of Medicare drug
  3. 65% of Medicare DME
  4. 100% of Medicare anesthesia
  5. 90% of Medicare RVU
  6. 25% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
FL-UHC-Profee6 base · 18 adj
United Healthcare Commercial
Professional · FL · 2025-08-15 → 2999-12-31
Base terms — first match wins
  1. 45% of Medicare lab (rates as of 2020-01-01)
  2. 100% of Medicare drug
    • CodeRange 96401–96549 → 106%
  3. 60% of Medicare DME (rates as of 2020-01-01)
  4. 100% of Medicare anesthesia
  5. 100% of Medicare RVU (rates as of 2020-01-01)
    • CodeRange 70010–79999 → 80%
    • CodeRange 97000–97799 → 70%
    • CodeRange 90460–90474 → 85%
  6. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Medicare5 base · 18 adj
Medicare
Professional · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare anesthesia
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Medicare-ASC1 base · 20 adj
Medicare
Facility · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Sentara Medicaid-Profee3 base · 19 adj
Sentara Medicaid
Professional · VA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. custom SQL — VA Medicaid professional-fee lookup: resolves professional-component (modifier 26), technical-component (modifier TC), or global rate for a procedure code, gated by inpatient/outpatient place-of-service and patient age band, excluding rows flagged 'IC' (individually considered / no fixed rate).
  3. 100% of Medicare drug
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Tricare-Profee4 base · 19 adj
Tricare
Professional · VA · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Tricare-Drug fee schedule
  3. 100% of the Tricare-CMAC-Technical fee schedule
  4. 100% of the Tricare-CMAC fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
VA Medicaid Profees3 base · 19 adj
Medicaid
Professional · VA · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. custom SQL — VA Medicaid professional-fee lookup: resolves professional-component (modifier 26), technical-component (modifier TC), or global rate for a procedure code, gated by inpatient/outpatient place-of-service and patient age band, excluding rows flagged 'IC' (individually considered / no fixed rate).
  3. 100% of Medicare drug
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
VA-Aetna Medicaid-Profee3 base · 19 adj
Aetna Medicaid
Professional · VA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. custom SQL — Virginia Medicaid professional-fee lookup: picks a rate (professional-component-only, technical-component-only, or global) from a place-of-service/age/procedure-type-banded VA Medicaid fee table, keyed by the charge's modifier and the patient's age on the service date.
  3. 100% of Medicare drug
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
VA-Aetna Medicare Profee5 base · 18 adj
Aetna Medicare
Professional · VA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 96% of Medicare lab
  2. 96% of Medicare drug
  3. 96% of Medicare DME
  4. 100% of Medicare anesthesia
  5. 96% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-Anthem Managed Medicaid-Profee3 base · 19 adj
Anthem Managed Medicaid
Professional · VA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. custom SQL — VA Medicaid professional-fee lookup: resolves professional-component (modifier 26), technical-component (modifier TC), or global rate for a procedure code, gated by inpatient/outpatient place-of-service and patient age band, excluding rows flagged 'IC' (individually considered / no fixed rate).
  3. 100% of Medicare drug
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
VA-Anthem Medicare Profees5 base · 19 adj
Anthem Medicare Plans
Professional · VA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare anesthesia
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. modifier 55 present → 20% of the running amount
  9. modifier 56 present → 10% of the running amount
  10. modifier 62 present → 63% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
VA-Cigna Commercial (PPO,OAP) Profees3 base · 18 adj
Cigna OAP, Cigna PPO
Professional · ASC, Clinic, Hospital, VA · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. percent-of-charges, rate read from the VA-Cigna-PercentOfCharges schedule
  2. 100% of the VA-Cigna-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital, Home
  3. 100% of the VA-Cigna-Clinic-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-Cigna Medicare-Profee5 base · 18 adj
Cigna Medicare
Professional · ASC, Clinic, Hospital, VA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare anesthesia
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-Humana Medicare Profees5 base · 18 adj
Humana Medicare
Professional · VA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 50% of Medicare lab
  2. 100% of Medicare drug
  3. 75% of Medicare DME
  4. 100% of Medicare anesthesia
  5. 100% of Medicare RVU
    • CodeRange 97001–98943 → 80%
    • CodeRange 92506–92508 → 80%
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-Molina Medicaid-Profee3 base · 19 adj
Molina Medicaid
Professional · VA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. custom SQL — VA Medicaid professional-fee lookup: resolves professional-component (modifier 26), technical-component (modifier TC), or global rate for a procedure code, gated by inpatient/outpatient place-of-service and patient age band, excluding rows flagged 'IC' (individually considered / no fixed rate).
  3. 100% of Medicare drug
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
VA-Novitas-Anthem/BCBS VA Key Care PPO-Profee1 base · 18 adj
Anthem/BCBS VA Key Care PPO
Professional · VA-Novitas · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-Palmetto-Anthem Key Care PPO-Profee3 base · 18 adj
Anthem/BCBS VA Key Care PPO
Professional · VA-Palmetto · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. 100% of the VA-Palmetto-Anthem Key Care PPO-Facility-Profee-2025 fee schedule
  3. 100% of the VA-Palmetto-Anthem Key Care PPO-NonFacility-Profee-2025 fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-UHC Commercial Profees1 base · 18 adj
United Healthcare Commercial
Professional · ASC, Clinic, Hospital, VA · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the VA-UHC-Clinic-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-United Healthcare Managed Medicaid-Profee3 base · 19 adj
United Healthcare Managed Medicaid
Professional · VA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. custom SQL — VA Medicaid professional-fee lookup: resolves professional-component (modifier 26), technical-component (modifier TC), or global rate for a procedure code, gated by inpatient/outpatient place-of-service and patient age band, excluding rows flagged 'IC' (individually considered / no fixed rate).
  3. 100% of Medicare drug
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
VA-United Healthcare Medicare5 base · 18 adj
United Healthcare Medicare
Professional · VA · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare anesthesia
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges